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Research articles and comments
Internatmnal PrInted
Journal
I” the
L. S.A.
of Law All
rights
and Psych/my,
Vol.
1, pp.
427-436.
1978
0160.2527/78/040427-10$02.00/O Copyright
reserved
0
1979
Pergamon
Press
Ltd
RESEARCH ARTICLES AND COMMENTS Developing Community
Mental Health Center-
Criminal Justice System Interactions Robert
L. Sadoff*
The mentally ill person who is accused of a crime usually faces the worst of both the legal and mental health systems before and after conviction. Mixing the power of the legal system with the power of the mental health system leads to harmful and philosophically indefensible results rather than to amelioration of the harshness of the legal system. I Introduction
Newer legislation in the field of mental health, and recent court decisions, have drastically altered the care and treatment of the mentally ill. This is true especially for the right to treatment cases of the 1960’s. the right to refuse treatment provisions of the 1970’s, and the spate of legislation that has occurred in virtually every state; restricting the involuntary commitment of mentally ill persons to those who are both mentlly ill and “dangerous.” either to themselves or to others. Legislators have justified the newer commitment laws on the basis of due process, but also on the basis of economic feasibility. They have argued that it is cheaper to treat individuals in the community than to enlarge state hospitals; they have allocated funds where they will be put to the most efficient use. It may be true that inadequate mental health care in the community is cheaper than inadequate mental health care in hospitals. but I submit that adequate mental health care in the community is far more expensive, financially, than even adequate hospital care. It seems we have provided for only half the needs of our mentally ill citizens during this period of transition: i.e.. we have effectively kept a number of people out of state hospitals who do not wish to be there. In effect, we have also kept a number of mentally ill persons out of state hospitals who do wish to be there. What have we provided for them in the alternative? Where are the community resources we promised the families of our mentally ill in place of the expensive hospitals we have promised to keep them out of? *Associate Clinical Professor of Psychiatryand Director. Center for Studies in Social-Legal Psychiatry, University of Pennsylvania. Suite 326, The Benjamin Franklin Fox Pavilion. Jenkintown, Pennsylvania, 19046. ‘N. Morris, qpeakinp at AAPL Institute of Psychiatry Conference, Chicago. Ill., March, 1978.
427
428
ROBERT
L. SADOFF
To further add to the woes of the mentally ill, their families and the communities, the newer legislation has also mandated that we discharge hundreds of mentally ill persons who no longer meet the criteria for continued hospitalization. In some cases courts have been called upon to exercise their power of authority to ensure the release of individuals from hospitals. Again, releasing patients from the hospitals is only half the promise; the other half lies in the community. To what facilities are we releasing these individuals, many of whom have spent virtually their entire adult lives in the hospital? Undoubtedly the legislators and judges are relying upon present facilities, primarily the Community Mental Health Centers, which have not met the comprehensive demands and needs of those retained in or returned to the community. It seems to me a number of significant problems have arisen because of the changes in laws and their effect upon people and upon currently established institutions. I will confine my remarks to the effect these changes have had on the interface of the mental health and criminal justice systems and suggest alternative solutions, where possible. Criminalizing
the Mentally
Ill, Or Psychiatrizing
the Criminal
Let us take a person in the community who begins to show signs of mental illness and erratic behavior. Formerly, this individual was examined by one or two psychiatrists and, if found to be mentally ill and in need of hospitalization, he was so certified and often committed for treatment. Today this person would not be eligible for involuntary hospitalization unless his erratic behavior was either threatening or harmful to others or to his own life. In some states his behavior may be so erratic that it constitutes a significant threat to his well being and his physical health such that he may be considered “gravely disabled.” However, in most states this individual would not be commitable. The libertarians would say he has not done anything “wrong” or “criminal” so he cannot be locked up. The physicians would be disturbed because they would see signs of impending deterioration and would want to treat a sick person. However, preventive medicine, except for infectious diseases, has become a dirty word and is linked to such phrases as “psychiatrization,” “therapeutic state,” “medicalization,” etc. Today we have to wait until the person either deteriorates to the point of serious mental illness, to the point of death, or to the point that he harms or kills someone else. If he kills himself there appears to be no problem, for there is no patient and there are no concerns about facilities to care for him, except to bury him. If he deteriorates sufficiently, he may be regarded as “gravely disabled” and be hospitalized for care and treatment; or, if he hurts someone else, he can then be hospitalized. In Pennsylvania, as in many other states, his act of hurting someone else constitutes a crime and he may be treated by the criminal justice system rather than by the mental health system. Some have referred to the effect the mentally ill.“[’ 1 In Pennsylvania, of restrictive legislation as “criminalizing where a threat is considered to be an assault, i.e., a crime, it is often easier to ‘I. Perr and D. A. Treffert. both speaking at the American Ga., May, 1978, Quoted in CIinicalPsychiatryNews 6:7 (July,
Psychiatric 1978):3.
Association
Meeting
in Atlanta,
CMHC-CRIMINAL
JUSTICE
SYSTEM
INTERACTION
429
take into custody an individual who threatens another and have him charged with a crime than it is to apprehend and confine a mentally ill person who “only threatened.” The standards become arbitrary and open to interpretation by various individuals in authority. In essence, then, in many cases it is easier for a psychiatrist to recommend to a family concerned about a relative who is acting bizarrely, and who has a history of mental illness, to seek help for their relative through the criminal justice system rather than through the mental health system. Many psychiatrists advocate arresting such individuals for two reasons. First, and most importantly, because the person needs immediate attention which is best obtained, in many cases, by arrest and confinement through the criminal justice system rather than through the restrictive, often odious measures instituted under the mental health system. This assumes, of course, an unwilling patient, one who does not wish to go to the Community Mental Health Center for treatment; one who does not believe there is anything wrong with him but only with others; one who has a right not to be confined in a hospital even when he has committed a crime, i.e., a crime of assault by threat. The second reason is a more political one, motivated by the concern that the law has not provided alternative mechanisms to help those whom it has restricted from hospital care. It is a wish to emphasize the extremes to which one must go in order to help a person who is in need but who does not recognize that fact. It is truly an abuse of the system because it really does not help the patient to have him arrested, with charges on his record. Further, it doesn’t help the criminal justice system do its job for those who are criminal and not mentally ill, and finally, it is not fair to the families who are kept from adequate medical care for their members. However, it is a technique that is employed because it works more effectively in some cases than does the current relatively ineffective mental health system which is still in transition, seeking its own level. It is this transitional phase in the system that I wish to address in order, hopefully, to influence needed changes to accomplish similar goals. Suppose the person in question is arrested and is sent to the county prison. Will he receive proper psychiatric treatment ? In large cities such as Philadelphia, Pittsburgh, New York, Boston, and others, there are psychiatric services to the county prison where the individual will receive a proper evaluation and may even obtain a recommendation for transfer to the hospital under the criminal commitment sections of the law. In smaller counties, there are not adequate psychiatric services to the county prisons, and if a person’s behavior is not properly detected or called to official attention, he may not receive adequate psychiatric treatment. What can be done ? This issue was raised before the Governor’s Commission on the Mentally Ill Offender in Pennsylvania (1977) and recommendations were made for provision of adequate psychiatric, diagnostic, evaluation and treatment services in the county prisons throughout the state. Increasing the psychiatric services to the state correctional institutions was also recommended in order to provide treatment within a person’s home environment, whether it be the county prison or the state penitentiary. It was felt that more optimal treatment could be given to many people in those locations under proper environmental control than by transferring the person to a state hospital or to a special hospital for the “criminally insane.” Such a program has been established at the Bucks County Prison outside of
430
ROBERT
L. SADOFF
Philadelphia. The proper coordination of tile criminal justice systenl and the mental health system has led to integration of servictx within the count)- prison provided by conimunity mental health personnel and others. m existence of the therapeutic coninii~nity. a drug treatment program, and coniprehtmsivc diacmostic and evaluation services has been continuous for several years. I7 Montgomery County, Pennsylvania has developed a coordinated program brtween cornniLinity mental hcaltli and criminal justice systems through a project Basically, the emergency sercalled. “Montgomery County Emergency Service.” vice handles crises wlierc mental illness and criminaljustice come directly togt’ther. These cases include drug abuse. alcohol intoxication. child ahuxc and others. where the individuals involved ina>’ he in need of but11 security and treatment. Formerly. the police had two altc~rnativcx: omit’ \vas the community mental health center or a local hospital, and the othc,r was a lock-up or ;I prison. Unfortunately soii~t‘ of the alcoliolicb died in the c~ounty jail witlio(it proper trcatlnent, as did somt ot‘ the drug addicts. Many Iloxpital\ could not provitic’ hot11 \ccurity and treatment. and patizlits often would elope williout receiving proper care or treatment. Building 1h. oil tlir grounds of the Norristown .State IIospital, is tliil etnergcncy center which operattls 74 hours per day and provides, uncicr medical supervision. a place for individiials to conit‘ who require hotti scciirity and treatment. This is an emergrncy service which provides treatment for a limit& time L)y properly intcgratin g tlic services 01‘ criminal justice and community mental health center personnel for the knct‘it of the pitit‘nt. Formerly. tliesc cmergencirs were not as well Iiandl~cl I~wairsc of the scparatt~ntm of tlic two systems. Hospitals did not wish to he prisons and prisons did not wish to lx hospitals. The solution st?t’tns yinlplc>: creatt‘ one institution whic~h can serve tht, best functions of both ;I reasonaklc altt‘rnative to tlic c‘iirrixnt syslrm whi~~li separate5 the services provided for tli c iilentally ill who may alxo hc violent to thrniselvcs or to others. Another 111ajor effect resulting i‘rom the cllangc in 1cgisl:ition is the discharge of great ntiinbcrs of patients into the zotlimunity without properI\, prcpariiip tllc comniuni~y in advance. Court5 liavt~ nianclatcd liundri~ti~ of patients to be discharged from hospitals. but rareI>, have they ~ndnciat~cl the type ot‘ services requirt‘d in the community. Some Ii;i~.c cotnplain~tl that palicnts have hct~n “dLllllped“ into the cotiiniiinit~ ’ ghettos where tlicy arc iinproperly prrparc‘cl to care for themselves and many ot‘tcn die of nc~glcct or social al3usc. ,IIany are robbed. raped. tiiug~~d and vcarii i’or return to tile scctirit\ 01‘ tlif hospital. Do these discharged patients have riglits in tlic community 3s the), had iii the lick pitals’l Priscilla Allen. hl~nibt~r ot’ the i’rt2sidcnt’s C’otiiniissiou 011 hlcntal Ilcaltli. and 3 t‘ormer patient. clcarlv doc~lnicnts the plight 01‘ those sciit for outpatient treatment and prcst’nts ;I bill 01 riglIt\ for- otitpaticnts. These 21-c riglits that arc’ visually at‘forclcti to paticiit:, who ;iri’ Ilo5pitalir.txi and otlicrs. hut for some reason. she believe5 tlicy Iiavt’ hecti cicnicd to outlxiticlits disc.l1argt~d from hospitals.’ What of the patit‘n ts cmcrging t‘rom Ilospitals into tllc‘ comtnunities? At-e they more ciangzt‘rous than those wlic) have never hccti !iospitali/ecl? Do we need
CMHC-CRIMINAL
JUSTICE
SYSTEM
INTERACTION
431
to take proper precautions before pouring them into our communities? What facilities must we develop in conjunction with criminal justice to help deal with this flow of humanity? Sosowski4 compared arrest rates of 301 former state mental patients with those of the local county population. He found the patients had a markedly higher incidence of arrest for criminal behavior, including violent offenses, than those in the comparison groups. His findings are at variance with earlier studies, but in general are in agreement with more recent studies such as those of Zitrin” who suggests the increasing diversion of arrested persons from the criminal justice system to mental hospitals is a factor that might be responsible for the apparent rise in criminal behavior in mental patients. This is not supported by the earlier studies of Rappeport and Lassen, who found no higher incidence of violent behavior among former mental patients than in comparison groups. Sosowski concludes, “it may be true that the mentally ill, traditionally treated in state hospitals. are more violent than the general public and that more liberty does result in more crime and violence.” Steadman, Cocozza and Melick compare the arrest rates of nearly 2.000 psychiatric patients released from psychiatric centers in 1968 and those of nearly 7.000 patients released in 1975. with a group of 5,000 patients studied 35 years earlier. They conclude, “in general, arrest rates among the two recent samples were considerably higher than general population rates. primarily because of the large proportion of patients previously arrestsd.” One additional finding was that the number of patients with prior arrests had markedly increased over the years. In attempting to explain the increasing arrest rate among former mental patients, the authors state. “dominant among these suggestsions has been that recent community treatment ideologies and programs have put more persons who are at risk of arrest into the community. Further, this explanation is pointed to the over-reactions to such programs in some states that have ‘dumped persons not ready for independent living into high crime areas.” Further they state, “While these developments may have contributed to what we have found over a 30 year period in New York, a muc11 more parsimonious explanation, which can be empirically supported from the data reported here, is that the composition of state hospital populations has changed in ways directly related to increasing the probability of post-release arrest.” Thus we see, from various sources and different studies, a tendency toward greater arrest rates among released hospital patients. This means we must continue to develop programs in the community, not only to take care of those individuals who are denied hospitalization and require treatment, either to prevent or to mitigate criminal behavior, but we must also provide special ti-eat“L. Sosowski. “Crime and Violence among Mental Patients Reconsidered in View of the New Legal Relationship between the State and the Mentally 111,“Ame~ J. Psychiatry 135 (1978):3342. 5A. Zitrin, A. S. Hardesty and E. L. Burdock et al., “Crime and Violence Among Mental Patients,” Amer. J Psychiatry 133 (1976):142-149. 6J. R. Rappeport and G. Lassen “A Review of the Literature on the Dangerousness of the Mentally Ill,” in J. R. Rappeport. ed.. The Clinical Evaluation of the Darzgerousness of the Mentally III (Springfield, Ill.: Chas. C. Thomas, 1967). ‘H. Steadman, J. Cocozza and M. E. Melick, “Explaining the Increased Arrest Rate among Mental Patients: The Chanping Clientele of the State Hospitals,” Amer. J. Psychiat. 135 t1978):816.
432
ROBERT
L. SADOFF
ment programs in the community for those who have been released from state hospitals, since the incidence of post-release arrest rate has been rising. As an example of this problem, recently I had been called to examine an individual who had been released from a state hospital and had attended a community mental health center for treatment upon release. During his period of outpatient treatment he left the area to travel to the south. He became increasingly nervous and anxious, and decided to return to Philadelphia. Upon his return he recognized that he was becoming acutely psychotic and required further treatment. He presented himself to the Community Mental Health Center where he had received treatment previously and told them he was in need of returning. They said it was 3:00 PM on Friday afternoon and he should come back on Monday and he would not be hospitalized till then. This person had a great imagination and an apparent knowledge of the intricacies and difficulties within the system. Since he could not be hospitalized legitimately, he chose an illegitimate route. Even though hospitals and mental health centers are not open after 3:00 on Friday, he knew that banks were. He went to the nearest bank, left a note, saying this was a robbery, took a few bills and waited outside the bank for the police to come and arrest him. When they did arrive he said, very politely, “It’s about time you got here, now please take me to the nearest hospital because I need help, I’m sick.” The police recognized that he was seriously disturbed, took him to the hospital. where he received treatment. I have included this as an example of “criminal behavior masking mental illness.“’ Special Community
Situations
There are situations which require special community handling and require programs that are not currently in existence. For example, I was recently called upon by a judge from a county near Philadelphia to examine and evaluate the competency of a young, aggressive, black, mentally retarded, deaf and dumb male, who was alleged to have assaulted a female in the institution for the mentally retarded. The judge could not communicate with this lad; interpreters for the deaf had great difficulty using sign language, since he was so mentally retarded and not able to learn the meaning of the signs. He could function in a county prison, awaiting trial, but he was not competent to stand trial and he could not be kept in the county prison much longer. He posed a threat of harm to others at the institution for the mentally retarded and could not go home. Where does the judge send a youngster of this type? A second challenge came from the same county, when I was asked to examine a 19-year-old single black male who had been institutionalized since the age of six. He had had opportunities for independent living in the community which were impossible because of his explosive behavior and his inability to be controlled at home. He was hospitalized because he had difficulty in the county prison. He had been to a number of special schools, state hospitals, hospitals for the retarded and a youth development center. The hospital believed he no longer required their services, nor could he benefit from them. He was “R. L. Sadoff. (1971):41.
“Criminal
Behavior
Masking
Mental Illness.”
Corr. Psychiatry and J. Sot. Therapy 17: 2
CMHC-CRIMINAL
JUSTICE
SYSTEM
INTERACTION
433
then in what was called a “holding pattern.” The district attorney was afraid of him and did not wish him in the community, and the judge did not know what to do with him. My job was to try to outline a special plan for him for community services, whether they existed or not. It was my opinion that he should be tried out of the hospital, but in what facility? The facility I described was a group home where he might obtain educational training, vocational skills, social skills, structural control when he becomes impulsive and overly aggressive. He did not require medication but he might require it in the future if he became overly aggressive or assaultive. I told the judge I did not know of such a facility except for those juvenile justice homes used for rehabilitation and training of adolescents. He had been to one of these homes at age 16 or 17 and required one now as an adult. Such a home does not exist but needs to be developed, especially for this type of individual. His prognosis is poor to guarded and the chances of staying out of institutional confinement for any significant period of time are quite limited, but every effort should be made to provide him with as much extra-mural care as can be allowed with proper security. The late Josph Peters, a prominent psychiatrist and psychoanalyst in Philadelphia, developed a system of group psychotherapy for sex offenders on probation. It was through his integration of services between community mental health centers and criminal justice, probation and parole, that he was able effectively to develop a treatment program for sex offenders in the community, using the controls of the probation department and the therapeutic skills of psychiatry and group psychotherapy. He tried integrating a probation officer as cotherapist in some of the groups to more closely align the two systems. The program is still in operation and has served as a model for other programs throughout the country.’ Francis Tyce, Chairman of the American Psychiatric Association Task Force on Psychiatric Rehabilitation, describes and advocates alternative correctional programs and particularly correctional programs that emphasize the use of community facilities such as half-way houses and group foster homes.‘O He discusses two dissimilar patterns of acute care services that are emerging: the use of skilled nursing facilities with additional staff to provide mental health services and the development of the wide range of primarily non-medical facilities under the licensing category of “Residential Care Facility.” Gordon” states that “the runaway centers that evolved in the late 1960’s in response to the needs of troubled young people are fulfilling many of the goals of the community mental health center movement. These centers provide the young client 5-day CMHC services - inpatient, outpatient, emergency, partial hospitalization and consultation and education in an individualized and economical manner. They can serve as a model for a variety of community services, such as drop-in centers for troubled individuals, medication centers for families, shelters for battered women and residences for people suffering an acute psychotic break.” This model may also serve to enhance the community mental health center-criminal justice interaction where necessary and appropriate. 9J. J. Peters and R. L. Sadoff, “Psychiatric Services for Sex Offenders on Probation,” (Sept. 1971):33-37. “see Psychiatric Annals 7 (1977):258. *lJ. Gordon, “The Runaway Center,” Amer. J. Psychiatry 135 (1978):932.
Fed. Probation
434
ROBERT
L. SADOFF
Others working in the field of corrections, parole and probation have developed alternative programs to incarceration, utilizing community mental health center personnel for mandatory treatment if a person is placed on probation. The CMHC is then under obligation to report to probation or parole if the patient violates the rules by not attending. It is important for the psychiatrist working in the community mental health center to assimilate information about alternative programs and to be able to work with persons in criminal justice systems in order to be familiar with community programs for total rehabilitation and to aid in the development of those programs that are needed but do not currently exist. Thus far we have discussed the need for interaction and integration of programs in the community between mental health and criminal justice systems. We have seen the need to prevent people from deteriorating to the point where they will require emergency medical care or will be arrested for erratic behavior. A study in California (Enki)” reported that some of the individuals who were in treatment but who were restricted from involuntary hospitalization had deteriorated in the community without proper help. and eventually came into contact with law enforcement officials and were imprisoned. We need to develop cooperative integrated programs to help these people. We can no longer say. “he is not mentally ill and dangerous. we can’t help him. we can’t hospitalize him.” We can no longer say he hasn’t committed a crime so we can’t imprison him. What can we do for him in the community working together with criminal justice to provide proper facilities for treatment’? Educational
Programs
Leading
to Pratical
Solutions
Educational programs between and among personnel of community mental health and criminal justice systems are necessary and often can lead to practical solutions or appropriate facilities for care and treatment of the mentally ill in our communities. As an example of such educational programs. one was instituted for drug abuse in 1970 by the Bucks County Bar Association in Pennsylvania on Law Day. They took the leadership in educating youngsters in high schools about problems of drugs and dru g abuse. On each speaking team there was a lawyer. a narcotics agent. a physician and a former addict addressing the youngsters. Those talks and the subsequent integration of criminal justice, law enforcement and mental health, eventually led to the development of the drug treatment program called TODAY. Inc., which has been thriving and caring for the needs of youngsters in the Bucks County Area with the help of the community mental health system and the Law Enforcement Administrative Agency (LEAA). Further educational programs involved psychiatrists and psychologists training police officers in problems of mental illness and giving sensitivity training. Coordinated programs of education among law enforcement and community mental health for optimal care of those individuals who traversed both systems have been developing and growing. Many individuals require the services of
CMHC-CRIMINAL
JUSTICE
SYSTEM
INTERACTION
435
both mental health and criminal justice. We need further dialogue and education between and among the systems and we need facilities that have input by both, such as Building 16, in order to properly care for emergency situations and also to continue to work toward prevention of violence. One program that was proposed recently, by the University of Pennsylvania Center for Studies in Social-Legal Psychiatry, was evaluation at an early level, in the municipal court, of those individuals who were brought before the judge with complaints of family violence. neighborhoood or community conflicts. Very often these early squabbles are the forerunners of later homicides. We wanted to try to do two things: firstly, to see if we could identify those individuals who may later progress to more violent eruptions unless some effective intervention was sought at an early time and secondly, we hoped to study the situational and psychological factors involved in the development of subsequent violence. Are there aspects within the family, within the individual, within the community, that we might point to as trouble signs or harbingers of future violence? There are many who remind us that psychiatrists cannot predict dangerousness; I am one of the advocates of that position, except under certain clinical guidelines. However, the law has mandated that we aid the community in the prediction of violent behavior and the determination of “dangerousness” with mental illness. It behooves us. then. to attempt to establish reasonable guidelines within a clinical format that we may utilize more effectively than the guidelines that currently exist.
Summary In summary the community mental health center personnel need to be able to work more effectively with criminal justice system personnel because of changes in laws and recent court decisions that have affected the treatment of the mentally ill in our communities. For example, community mental health personnel need to know about concepts of dangerousness, about qualification for involuntary hospitalization, for testifying at hearings under cross-examination regarding behavior, prediction of future behavior and need for control and treatment. They need to know about confidentiality of information that is received especially when working in conjunction with criminal justice system and they need to know the concept of privileged communications. Where does the patient have a privilege with respect to his treatment at a community mental health center. especially when he is on probation or parole? When must the community mental health center turn records over to courts or other criminal justice officials, and what safeguards are built into the system? With the changes in laws. the community mental health personnel may be required to evaluate a person charged with crime not only for competency to stand trial or for competency at the time he made a confession, but also for evaluation of criminal responsibility at the time of the crime. How much information is required in order for a psychiatrist to be able properly to evaluate an individual for criminal responsibility? Must he examine other data or documents, must he interview other individuals besides the patient in order to come to a reasonable opinion about criminal responsibility? What guidelines will be
436
ROBERT
L. SADOFF
established by community mental health centers with respect to the conducting of such examinations, evaluations and subsequent testimony? The community mental health personnel will need to know how to treat those people on probation or parole or those awaiting trial or on bail. What are the special precautions and the special relationship problems that exist with those people who are traversing both community mental health and criminal justice systems? The community mental health center will also need to know about domestic relations and family violence. This is perhaps one of the most important areas in which interaction between criminal justice and community mental health exists. Sexual abuse, child abuse, and wife battering are all significant aspects of this interaction. The treatment of juveniles who are involved in antisocial behavior or who are on probation or parole within the juvenile justice system needs clarification within community mental health centers. What other facilities are available for rehabilitation of juveniles, and how do juvenile justice system rules differ from adult criminal justice systems? Finally, there are a number of civil problems; workmen’s compensation, civil competency, and personal injury matters, for example, which may come to the attention of community mental health center personnel. Many of these may not directly involve the criminal justice system, but some may have criminal justice system overtones. Some are involved in both civil and criminal matters. We have attempted to outline a number of areas in which community mental health and criminal justice system interaction is required. It is essential that we work together to help those individuals who require services from both systems. These are individuals who emerge from prison or from state hospitals who are likely to have difficulty again. We need to develop programs and facilities in the community by joint efforts of criminal justice and community mental health that neither system has yet been able to provide alone. We need to deal more effectively with the mentally retarded, the physically handicapped, the brain damaged, the alcoholic, the drug addict. the psychotic, the juvenile, all of whom have the potential for violent behavior or criminal behavior within a framework of mental illness. Though the systems are ideologically separate, and perhaps must remain so, there are areas within our functioning that require mutual cooperation in order to provide more effective care and treatment in the community for the mentally ill person who has been or may become a criminal offender.
Journal
I” the
L. S.A.
of Law All
rights
and Psych/my,
Vol.
1, pp.
427-436.
1978
0160.2527/78/040427-10$02.00/O Copyright
reserved
0
1979
Pergamon
Press
Ltd
RESEARCH ARTICLES AND COMMENTS Developing Community
Mental Health Center-
Criminal Justice System Interactions Robert
L. Sadoff*
The mentally ill person who is accused of a crime usually faces the worst of both the legal and mental health systems before and after conviction. Mixing the power of the legal system with the power of the mental health system leads to harmful and philosophically indefensible results rather than to amelioration of the harshness of the legal system. I Introduction
Newer legislation in the field of mental health, and recent court decisions, have drastically altered the care and treatment of the mentally ill. This is true especially for the right to treatment cases of the 1960’s. the right to refuse treatment provisions of the 1970’s, and the spate of legislation that has occurred in virtually every state; restricting the involuntary commitment of mentally ill persons to those who are both mentlly ill and “dangerous.” either to themselves or to others. Legislators have justified the newer commitment laws on the basis of due process, but also on the basis of economic feasibility. They have argued that it is cheaper to treat individuals in the community than to enlarge state hospitals; they have allocated funds where they will be put to the most efficient use. It may be true that inadequate mental health care in the community is cheaper than inadequate mental health care in hospitals. but I submit that adequate mental health care in the community is far more expensive, financially, than even adequate hospital care. It seems we have provided for only half the needs of our mentally ill citizens during this period of transition: i.e.. we have effectively kept a number of people out of state hospitals who do not wish to be there. In effect, we have also kept a number of mentally ill persons out of state hospitals who do wish to be there. What have we provided for them in the alternative? Where are the community resources we promised the families of our mentally ill in place of the expensive hospitals we have promised to keep them out of? *Associate Clinical Professor of Psychiatryand Director. Center for Studies in Social-Legal Psychiatry, University of Pennsylvania. Suite 326, The Benjamin Franklin Fox Pavilion. Jenkintown, Pennsylvania, 19046. ‘N. Morris, qpeakinp at AAPL Institute of Psychiatry Conference, Chicago. Ill., March, 1978.
427
428
ROBERT
L. SADOFF
To further add to the woes of the mentally ill, their families and the communities, the newer legislation has also mandated that we discharge hundreds of mentally ill persons who no longer meet the criteria for continued hospitalization. In some cases courts have been called upon to exercise their power of authority to ensure the release of individuals from hospitals. Again, releasing patients from the hospitals is only half the promise; the other half lies in the community. To what facilities are we releasing these individuals, many of whom have spent virtually their entire adult lives in the hospital? Undoubtedly the legislators and judges are relying upon present facilities, primarily the Community Mental Health Centers, which have not met the comprehensive demands and needs of those retained in or returned to the community. It seems to me a number of significant problems have arisen because of the changes in laws and their effect upon people and upon currently established institutions. I will confine my remarks to the effect these changes have had on the interface of the mental health and criminal justice systems and suggest alternative solutions, where possible. Criminalizing
the Mentally
Ill, Or Psychiatrizing
the Criminal
Let us take a person in the community who begins to show signs of mental illness and erratic behavior. Formerly, this individual was examined by one or two psychiatrists and, if found to be mentally ill and in need of hospitalization, he was so certified and often committed for treatment. Today this person would not be eligible for involuntary hospitalization unless his erratic behavior was either threatening or harmful to others or to his own life. In some states his behavior may be so erratic that it constitutes a significant threat to his well being and his physical health such that he may be considered “gravely disabled.” However, in most states this individual would not be commitable. The libertarians would say he has not done anything “wrong” or “criminal” so he cannot be locked up. The physicians would be disturbed because they would see signs of impending deterioration and would want to treat a sick person. However, preventive medicine, except for infectious diseases, has become a dirty word and is linked to such phrases as “psychiatrization,” “therapeutic state,” “medicalization,” etc. Today we have to wait until the person either deteriorates to the point of serious mental illness, to the point of death, or to the point that he harms or kills someone else. If he kills himself there appears to be no problem, for there is no patient and there are no concerns about facilities to care for him, except to bury him. If he deteriorates sufficiently, he may be regarded as “gravely disabled” and be hospitalized for care and treatment; or, if he hurts someone else, he can then be hospitalized. In Pennsylvania, as in many other states, his act of hurting someone else constitutes a crime and he may be treated by the criminal justice system rather than by the mental health system. Some have referred to the effect the mentally ill.“[’ 1 In Pennsylvania, of restrictive legislation as “criminalizing where a threat is considered to be an assault, i.e., a crime, it is often easier to ‘I. Perr and D. A. Treffert. both speaking at the American Ga., May, 1978, Quoted in CIinicalPsychiatryNews 6:7 (July,
Psychiatric 1978):3.
Association
Meeting
in Atlanta,
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take into custody an individual who threatens another and have him charged with a crime than it is to apprehend and confine a mentally ill person who “only threatened.” The standards become arbitrary and open to interpretation by various individuals in authority. In essence, then, in many cases it is easier for a psychiatrist to recommend to a family concerned about a relative who is acting bizarrely, and who has a history of mental illness, to seek help for their relative through the criminal justice system rather than through the mental health system. Many psychiatrists advocate arresting such individuals for two reasons. First, and most importantly, because the person needs immediate attention which is best obtained, in many cases, by arrest and confinement through the criminal justice system rather than through the restrictive, often odious measures instituted under the mental health system. This assumes, of course, an unwilling patient, one who does not wish to go to the Community Mental Health Center for treatment; one who does not believe there is anything wrong with him but only with others; one who has a right not to be confined in a hospital even when he has committed a crime, i.e., a crime of assault by threat. The second reason is a more political one, motivated by the concern that the law has not provided alternative mechanisms to help those whom it has restricted from hospital care. It is a wish to emphasize the extremes to which one must go in order to help a person who is in need but who does not recognize that fact. It is truly an abuse of the system because it really does not help the patient to have him arrested, with charges on his record. Further, it doesn’t help the criminal justice system do its job for those who are criminal and not mentally ill, and finally, it is not fair to the families who are kept from adequate medical care for their members. However, it is a technique that is employed because it works more effectively in some cases than does the current relatively ineffective mental health system which is still in transition, seeking its own level. It is this transitional phase in the system that I wish to address in order, hopefully, to influence needed changes to accomplish similar goals. Suppose the person in question is arrested and is sent to the county prison. Will he receive proper psychiatric treatment ? In large cities such as Philadelphia, Pittsburgh, New York, Boston, and others, there are psychiatric services to the county prison where the individual will receive a proper evaluation and may even obtain a recommendation for transfer to the hospital under the criminal commitment sections of the law. In smaller counties, there are not adequate psychiatric services to the county prisons, and if a person’s behavior is not properly detected or called to official attention, he may not receive adequate psychiatric treatment. What can be done ? This issue was raised before the Governor’s Commission on the Mentally Ill Offender in Pennsylvania (1977) and recommendations were made for provision of adequate psychiatric, diagnostic, evaluation and treatment services in the county prisons throughout the state. Increasing the psychiatric services to the state correctional institutions was also recommended in order to provide treatment within a person’s home environment, whether it be the county prison or the state penitentiary. It was felt that more optimal treatment could be given to many people in those locations under proper environmental control than by transferring the person to a state hospital or to a special hospital for the “criminally insane.” Such a program has been established at the Bucks County Prison outside of
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Philadelphia. The proper coordination of tile criminal justice systenl and the mental health system has led to integration of servictx within the count)- prison provided by conimunity mental health personnel and others. m existence of the therapeutic coninii~nity. a drug treatment program, and coniprehtmsivc diacmostic and evaluation services has been continuous for several years. I7 Montgomery County, Pennsylvania has developed a coordinated program brtween cornniLinity mental hcaltli and criminal justice systems through a project Basically, the emergency sercalled. “Montgomery County Emergency Service.” vice handles crises wlierc mental illness and criminaljustice come directly togt’ther. These cases include drug abuse. alcohol intoxication. child ahuxc and others. where the individuals involved ina>’ he in need of but11 security and treatment. Formerly. the police had two altc~rnativcx: omit’ \vas the community mental health center or a local hospital, and the othc,r was a lock-up or ;I prison. Unfortunately soii~t‘ of the alcoliolicb died in the c~ounty jail witlio(it proper trcatlnent, as did somt ot‘ the drug addicts. Many Iloxpital\ could not provitic’ hot11 \ccurity and treatment. and patizlits often would elope williout receiving proper care or treatment. Building 1h. oil tlir grounds of the Norristown .State IIospital, is tliil etnergcncy center which operattls 74 hours per day and provides, uncicr medical supervision. a place for individiials to conit‘ who require hotti scciirity and treatment. This is an emergrncy service which provides treatment for a limit& time L)y properly intcgratin g tlic services 01‘ criminal justice and community mental health center personnel for the knct‘it of the pitit‘nt. Formerly. tliesc cmergencirs were not as well Iiandl~cl I~wairsc of the scparatt~ntm of tlic two systems. Hospitals did not wish to he prisons and prisons did not wish to lx hospitals. The solution st?t’tns yinlplc>: creatt‘ one institution whic~h can serve tht, best functions of both ;I reasonaklc altt‘rnative to tlic c‘iirrixnt syslrm whi~~li separate5 the services provided for tli c iilentally ill who may alxo hc violent to thrniselvcs or to others. Another 111ajor effect resulting i‘rom the cllangc in 1cgisl:ition is the discharge of great ntiinbcrs of patients into the zotlimunity without properI\, prcpariiip tllc comniuni~y in advance. Court5 liavt~ nianclatcd liundri~ti~ of patients to be discharged from hospitals. but rareI>, have they ~ndnciat~cl the type ot‘ services requirt‘d in the community. Some Ii;i~.c cotnplain~tl that palicnts have hct~n “dLllllped“ into the cotiiniiinit~ ’ ghettos where tlicy arc iinproperly prrparc‘cl to care for themselves and many ot‘tcn die of nc~glcct or social al3usc. ,IIany are robbed. raped. tiiug~~d and vcarii i’or return to tile scctirit\ 01‘ tlif hospital. Do these discharged patients have riglits in tlic community 3s the), had iii the lick pitals’l Priscilla Allen. hl~nibt~r ot’ the i’rt2sidcnt’s C’otiiniissiou 011 hlcntal Ilcaltli. and 3 t‘ormer patient. clcarlv doc~lnicnts the plight 01‘ those sciit for outpatient treatment and prcst’nts ;I bill 01 riglIt\ for- otitpaticnts. These 21-c riglits that arc’ visually at‘forclcti to paticiit:, who ;iri’ Ilo5pitalir.txi and otlicrs. hut for some reason. she believe5 tlicy Iiavt’ hecti cicnicd to outlxiticlits disc.l1argt~d from hospitals.’ What of the patit‘n ts cmcrging t‘rom Ilospitals into tllc‘ comtnunities? At-e they more ciangzt‘rous than those wlic) have never hccti !iospitali/ecl? Do we need
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to take proper precautions before pouring them into our communities? What facilities must we develop in conjunction with criminal justice to help deal with this flow of humanity? Sosowski4 compared arrest rates of 301 former state mental patients with those of the local county population. He found the patients had a markedly higher incidence of arrest for criminal behavior, including violent offenses, than those in the comparison groups. His findings are at variance with earlier studies, but in general are in agreement with more recent studies such as those of Zitrin” who suggests the increasing diversion of arrested persons from the criminal justice system to mental hospitals is a factor that might be responsible for the apparent rise in criminal behavior in mental patients. This is not supported by the earlier studies of Rappeport and Lassen, who found no higher incidence of violent behavior among former mental patients than in comparison groups. Sosowski concludes, “it may be true that the mentally ill, traditionally treated in state hospitals. are more violent than the general public and that more liberty does result in more crime and violence.” Steadman, Cocozza and Melick compare the arrest rates of nearly 2.000 psychiatric patients released from psychiatric centers in 1968 and those of nearly 7.000 patients released in 1975. with a group of 5,000 patients studied 35 years earlier. They conclude, “in general, arrest rates among the two recent samples were considerably higher than general population rates. primarily because of the large proportion of patients previously arrestsd.” One additional finding was that the number of patients with prior arrests had markedly increased over the years. In attempting to explain the increasing arrest rate among former mental patients, the authors state. “dominant among these suggestsions has been that recent community treatment ideologies and programs have put more persons who are at risk of arrest into the community. Further, this explanation is pointed to the over-reactions to such programs in some states that have ‘dumped persons not ready for independent living into high crime areas.” Further they state, “While these developments may have contributed to what we have found over a 30 year period in New York, a muc11 more parsimonious explanation, which can be empirically supported from the data reported here, is that the composition of state hospital populations has changed in ways directly related to increasing the probability of post-release arrest.” Thus we see, from various sources and different studies, a tendency toward greater arrest rates among released hospital patients. This means we must continue to develop programs in the community, not only to take care of those individuals who are denied hospitalization and require treatment, either to prevent or to mitigate criminal behavior, but we must also provide special ti-eat“L. Sosowski. “Crime and Violence among Mental Patients Reconsidered in View of the New Legal Relationship between the State and the Mentally 111,“Ame~ J. Psychiatry 135 (1978):3342. 5A. Zitrin, A. S. Hardesty and E. L. Burdock et al., “Crime and Violence Among Mental Patients,” Amer. J Psychiatry 133 (1976):142-149. 6J. R. Rappeport and G. Lassen “A Review of the Literature on the Dangerousness of the Mentally Ill,” in J. R. Rappeport. ed.. The Clinical Evaluation of the Darzgerousness of the Mentally III (Springfield, Ill.: Chas. C. Thomas, 1967). ‘H. Steadman, J. Cocozza and M. E. Melick, “Explaining the Increased Arrest Rate among Mental Patients: The Chanping Clientele of the State Hospitals,” Amer. J. Psychiat. 135 t1978):816.
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ment programs in the community for those who have been released from state hospitals, since the incidence of post-release arrest rate has been rising. As an example of this problem, recently I had been called to examine an individual who had been released from a state hospital and had attended a community mental health center for treatment upon release. During his period of outpatient treatment he left the area to travel to the south. He became increasingly nervous and anxious, and decided to return to Philadelphia. Upon his return he recognized that he was becoming acutely psychotic and required further treatment. He presented himself to the Community Mental Health Center where he had received treatment previously and told them he was in need of returning. They said it was 3:00 PM on Friday afternoon and he should come back on Monday and he would not be hospitalized till then. This person had a great imagination and an apparent knowledge of the intricacies and difficulties within the system. Since he could not be hospitalized legitimately, he chose an illegitimate route. Even though hospitals and mental health centers are not open after 3:00 on Friday, he knew that banks were. He went to the nearest bank, left a note, saying this was a robbery, took a few bills and waited outside the bank for the police to come and arrest him. When they did arrive he said, very politely, “It’s about time you got here, now please take me to the nearest hospital because I need help, I’m sick.” The police recognized that he was seriously disturbed, took him to the hospital. where he received treatment. I have included this as an example of “criminal behavior masking mental illness.“’ Special Community
Situations
There are situations which require special community handling and require programs that are not currently in existence. For example, I was recently called upon by a judge from a county near Philadelphia to examine and evaluate the competency of a young, aggressive, black, mentally retarded, deaf and dumb male, who was alleged to have assaulted a female in the institution for the mentally retarded. The judge could not communicate with this lad; interpreters for the deaf had great difficulty using sign language, since he was so mentally retarded and not able to learn the meaning of the signs. He could function in a county prison, awaiting trial, but he was not competent to stand trial and he could not be kept in the county prison much longer. He posed a threat of harm to others at the institution for the mentally retarded and could not go home. Where does the judge send a youngster of this type? A second challenge came from the same county, when I was asked to examine a 19-year-old single black male who had been institutionalized since the age of six. He had had opportunities for independent living in the community which were impossible because of his explosive behavior and his inability to be controlled at home. He was hospitalized because he had difficulty in the county prison. He had been to a number of special schools, state hospitals, hospitals for the retarded and a youth development center. The hospital believed he no longer required their services, nor could he benefit from them. He was “R. L. Sadoff. (1971):41.
“Criminal
Behavior
Masking
Mental Illness.”
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then in what was called a “holding pattern.” The district attorney was afraid of him and did not wish him in the community, and the judge did not know what to do with him. My job was to try to outline a special plan for him for community services, whether they existed or not. It was my opinion that he should be tried out of the hospital, but in what facility? The facility I described was a group home where he might obtain educational training, vocational skills, social skills, structural control when he becomes impulsive and overly aggressive. He did not require medication but he might require it in the future if he became overly aggressive or assaultive. I told the judge I did not know of such a facility except for those juvenile justice homes used for rehabilitation and training of adolescents. He had been to one of these homes at age 16 or 17 and required one now as an adult. Such a home does not exist but needs to be developed, especially for this type of individual. His prognosis is poor to guarded and the chances of staying out of institutional confinement for any significant period of time are quite limited, but every effort should be made to provide him with as much extra-mural care as can be allowed with proper security. The late Josph Peters, a prominent psychiatrist and psychoanalyst in Philadelphia, developed a system of group psychotherapy for sex offenders on probation. It was through his integration of services between community mental health centers and criminal justice, probation and parole, that he was able effectively to develop a treatment program for sex offenders in the community, using the controls of the probation department and the therapeutic skills of psychiatry and group psychotherapy. He tried integrating a probation officer as cotherapist in some of the groups to more closely align the two systems. The program is still in operation and has served as a model for other programs throughout the country.’ Francis Tyce, Chairman of the American Psychiatric Association Task Force on Psychiatric Rehabilitation, describes and advocates alternative correctional programs and particularly correctional programs that emphasize the use of community facilities such as half-way houses and group foster homes.‘O He discusses two dissimilar patterns of acute care services that are emerging: the use of skilled nursing facilities with additional staff to provide mental health services and the development of the wide range of primarily non-medical facilities under the licensing category of “Residential Care Facility.” Gordon” states that “the runaway centers that evolved in the late 1960’s in response to the needs of troubled young people are fulfilling many of the goals of the community mental health center movement. These centers provide the young client 5-day CMHC services - inpatient, outpatient, emergency, partial hospitalization and consultation and education in an individualized and economical manner. They can serve as a model for a variety of community services, such as drop-in centers for troubled individuals, medication centers for families, shelters for battered women and residences for people suffering an acute psychotic break.” This model may also serve to enhance the community mental health center-criminal justice interaction where necessary and appropriate. 9J. J. Peters and R. L. Sadoff, “Psychiatric Services for Sex Offenders on Probation,” (Sept. 1971):33-37. “see Psychiatric Annals 7 (1977):258. *lJ. Gordon, “The Runaway Center,” Amer. J. Psychiatry 135 (1978):932.
Fed. Probation
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Others working in the field of corrections, parole and probation have developed alternative programs to incarceration, utilizing community mental health center personnel for mandatory treatment if a person is placed on probation. The CMHC is then under obligation to report to probation or parole if the patient violates the rules by not attending. It is important for the psychiatrist working in the community mental health center to assimilate information about alternative programs and to be able to work with persons in criminal justice systems in order to be familiar with community programs for total rehabilitation and to aid in the development of those programs that are needed but do not currently exist. Thus far we have discussed the need for interaction and integration of programs in the community between mental health and criminal justice systems. We have seen the need to prevent people from deteriorating to the point where they will require emergency medical care or will be arrested for erratic behavior. A study in California (Enki)” reported that some of the individuals who were in treatment but who were restricted from involuntary hospitalization had deteriorated in the community without proper help. and eventually came into contact with law enforcement officials and were imprisoned. We need to develop cooperative integrated programs to help these people. We can no longer say. “he is not mentally ill and dangerous. we can’t help him. we can’t hospitalize him.” We can no longer say he hasn’t committed a crime so we can’t imprison him. What can we do for him in the community working together with criminal justice to provide proper facilities for treatment’? Educational
Programs
Leading
to Pratical
Solutions
Educational programs between and among personnel of community mental health and criminal justice systems are necessary and often can lead to practical solutions or appropriate facilities for care and treatment of the mentally ill in our communities. As an example of such educational programs. one was instituted for drug abuse in 1970 by the Bucks County Bar Association in Pennsylvania on Law Day. They took the leadership in educating youngsters in high schools about problems of drugs and dru g abuse. On each speaking team there was a lawyer. a narcotics agent. a physician and a former addict addressing the youngsters. Those talks and the subsequent integration of criminal justice, law enforcement and mental health, eventually led to the development of the drug treatment program called TODAY. Inc., which has been thriving and caring for the needs of youngsters in the Bucks County Area with the help of the community mental health system and the Law Enforcement Administrative Agency (LEAA). Further educational programs involved psychiatrists and psychologists training police officers in problems of mental illness and giving sensitivity training. Coordinated programs of education among law enforcement and community mental health for optimal care of those individuals who traversed both systems have been developing and growing. Many individuals require the services of
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both mental health and criminal justice. We need further dialogue and education between and among the systems and we need facilities that have input by both, such as Building 16, in order to properly care for emergency situations and also to continue to work toward prevention of violence. One program that was proposed recently, by the University of Pennsylvania Center for Studies in Social-Legal Psychiatry, was evaluation at an early level, in the municipal court, of those individuals who were brought before the judge with complaints of family violence. neighborhoood or community conflicts. Very often these early squabbles are the forerunners of later homicides. We wanted to try to do two things: firstly, to see if we could identify those individuals who may later progress to more violent eruptions unless some effective intervention was sought at an early time and secondly, we hoped to study the situational and psychological factors involved in the development of subsequent violence. Are there aspects within the family, within the individual, within the community, that we might point to as trouble signs or harbingers of future violence? There are many who remind us that psychiatrists cannot predict dangerousness; I am one of the advocates of that position, except under certain clinical guidelines. However, the law has mandated that we aid the community in the prediction of violent behavior and the determination of “dangerousness” with mental illness. It behooves us. then. to attempt to establish reasonable guidelines within a clinical format that we may utilize more effectively than the guidelines that currently exist.
Summary In summary the community mental health center personnel need to be able to work more effectively with criminal justice system personnel because of changes in laws and recent court decisions that have affected the treatment of the mentally ill in our communities. For example, community mental health personnel need to know about concepts of dangerousness, about qualification for involuntary hospitalization, for testifying at hearings under cross-examination regarding behavior, prediction of future behavior and need for control and treatment. They need to know about confidentiality of information that is received especially when working in conjunction with criminal justice system and they need to know the concept of privileged communications. Where does the patient have a privilege with respect to his treatment at a community mental health center. especially when he is on probation or parole? When must the community mental health center turn records over to courts or other criminal justice officials, and what safeguards are built into the system? With the changes in laws. the community mental health personnel may be required to evaluate a person charged with crime not only for competency to stand trial or for competency at the time he made a confession, but also for evaluation of criminal responsibility at the time of the crime. How much information is required in order for a psychiatrist to be able properly to evaluate an individual for criminal responsibility? Must he examine other data or documents, must he interview other individuals besides the patient in order to come to a reasonable opinion about criminal responsibility? What guidelines will be
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established by community mental health centers with respect to the conducting of such examinations, evaluations and subsequent testimony? The community mental health personnel will need to know how to treat those people on probation or parole or those awaiting trial or on bail. What are the special precautions and the special relationship problems that exist with those people who are traversing both community mental health and criminal justice systems? The community mental health center will also need to know about domestic relations and family violence. This is perhaps one of the most important areas in which interaction between criminal justice and community mental health exists. Sexual abuse, child abuse, and wife battering are all significant aspects of this interaction. The treatment of juveniles who are involved in antisocial behavior or who are on probation or parole within the juvenile justice system needs clarification within community mental health centers. What other facilities are available for rehabilitation of juveniles, and how do juvenile justice system rules differ from adult criminal justice systems? Finally, there are a number of civil problems; workmen’s compensation, civil competency, and personal injury matters, for example, which may come to the attention of community mental health center personnel. Many of these may not directly involve the criminal justice system, but some may have criminal justice system overtones. Some are involved in both civil and criminal matters. We have attempted to outline a number of areas in which community mental health and criminal justice system interaction is required. It is essential that we work together to help those individuals who require services from both systems. These are individuals who emerge from prison or from state hospitals who are likely to have difficulty again. We need to develop programs and facilities in the community by joint efforts of criminal justice and community mental health that neither system has yet been able to provide alone. We need to deal more effectively with the mentally retarded, the physically handicapped, the brain damaged, the alcoholic, the drug addict. the psychotic, the juvenile, all of whom have the potential for violent behavior or criminal behavior within a framework of mental illness. Though the systems are ideologically separate, and perhaps must remain so, there are areas within our functioning that require mutual cooperation in order to provide more effective care and treatment in the community for the mentally ill person who has been or may become a criminal offender.